Payment Integrity Physician Reviewer

Clearlink Partners; United States; On-site; USD 138,000 - 207,000; Full time

Job summary

Clearlink Partners in the United States seeks a senior health care consultant with MD/DO licensing to guide payment integrity and medical management strategies for managed care clients. You will lead engagements, translate clinical and financial data into actionable plans, and present findings to client executives.

This role requires deep managed care expertise, regulatory acumen, and strong leadership across cross-functional teams.

Qualifications

• MD/DO physician licensed and board certified is required.
• Extensive knowledge of managed care policies and regulatory frameworks.
• Experience translating strategy into scalable healthcare programs.
• Strong leadership and cross-functional collaboration skills.

Responsibilities

• Provide strategic direction for health plan medical management and operations.
• Lead client engagements and deliver value through innovative solutions.
• Present findings and recommendations to client executives.
• Translate clinical, operational, and financial results into actionable plans.
• Coach staff and manage multiple complex projects concurrently.
• Ensure compliance with healthcare regulations and contractual terms.

Skills

Managed care

Strategic leadership

Regulatory compliance

CMS/NCQA knowledge

Education

Medical Degree (MD/DO)

Tools

Excel

Word

PowerPoint

Visio

Job description

Company Description

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities.

Clearlink Partners is an industry-leading managed care consultancy specializing in end-to-end clinical and operational management services and market expansion initiatives for Managed Medicaid, Medicare Advantage, Special Needs Plans, complex care populations, and risk-adjusted entities. We support organizations as they navigate a dynamic healthcare ecosystem by helping them manage risk, optimize healthcare spend, improve member experience, accelerate quality outcomes, and promote health equity.

Position Responsibilities

Specific

• Assess, develop, and optimize Payment Integrity programs to provide long-term, sustainable value.
• Support the implementation and execution of customized strategic initiatives designed to meet and exceed program and operational goals.
• Apply analytical and quantitative approaches to problem-solving and utilize statistical concepts to evaluate Payment Integrity opportunities and performance.
• Provide physician-level clinical expertise related to claims review, clinical validation, medical necessity, reimbursement, and complex provider payment matters.
• Support the review and resolution of complex clinical disputes, appeals, and reimbursement-related escalations.
• Collaborate with cross-functional teams and other stakeholders to identify and address payment accuracy opportunities.
• Translate clinical, operational, and financial findings into actionable recommendations for client leadership.

General

• Provide strategic direction for health plan market/ product medical management and health service operational oversight, management and performance
• Leverage advanced industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services
• Deliver innovative, integrated solutions in support of client goals and engagements.
• Lead engagements ensuring completion of all contracted services
• Present findings, recommendations and plans to Client executives
• Facilitate complicated problem-solving discussions to drive to timely, effective decision making
• Advise and persuade key decision makers and influencers
• Deliver concise, clear interpersonal communication to both internal and external audiences
• Facilitate streamlined executive summaries, next step recommendations and communication to all levels of Clearlink and client/ partner organization(s)
• Articulate performance across multiple projects with qualitative and quantitative results/ outcomes
• Influence others to best course of action through advanced understanding of changing business landscapes
• Develop strategies, goals and plans in response to changing business conditions
• Leverage best practice methodologies and approaches across individual account strategies/ client plans.
• Establish short term KPIs and long-term goals and track progress to ensure achievement
• Develop or update policies, procedures and workflows as required to support business needs and requirements
• Coach and mentor staff to reach established engagement goals, plan deliverables and KPIs
• Adapt process, approach, plan and/ or activities in real time to mitigate risk and ensure critical path activities
• Support account management relationships with key client decision makers

Competencies

Position Qualifications

• Advanced managed care industry expertise with C-Suite experience developing strategy, managing P&L, leading people, and ensuring contractual compliance
• Ability to translate trends, innovation, operations, financing, costs, requirements and performance into scalable activities and repeatable outcomes
• New product/ market strategy, design and implementation in the Commercial, Medicare, Medicare Advantage, Medicaid and/ or associated lines of business
• New population strategy development including identification, program design and implementation
• Operationalizing requirements for complex memberships, ensuring outcome delivery
• Expert understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures including compliance and remediation activity
• Ability to interpret and educate on complex concepts, requirements and legislation such as the Knox-Keene Act and HIPAA, State Department of Insurance requirements, Federal and State Health and Human Services requirements/ standards as well as CMS, NCQA, and URAC to ensure compliance with complex regulatory structures.
• Strategic leader with ability to produce, manage and maintain system-wide change through influence and persuasion
• Advanced knowledge of project management principles, methods, and techniques
• Ability to organize, prioritize, and manage multiple complex projects simultaneously
• Excellent communication skills both written and oral
• High proficiency with core office software (Excel, Word, and PowerPoint). Visio skills preferred

Experience

• Medical Degree (MD or DO) required; Must be actively licensed and current board certification
• Expertise in claims processing, provider contracts, data mining, and coordination of benefits, including fraud, waste, and abuse as they relate to provider payment.
• Demonstrated experience leading small- and large-scale process improvement initiatives.
• Experience in managed care, payment integrity, utilization management, clinical auditing, reimbursement, or related healthcare operations.
• Experience conducting clinical reviews and medical determinations for payment, reimbursement, or utilization decisions.
• Strong knowledge of CPT, ICD-10, HCPCS, clinical documentation, and reimbursement methodologies.
• Knowledge of payment policies, medical necessity criteria, clinical guidelines, and regulatory requirements.
• Experience managing complex provider disputes, appeals, and reimbursement escalations.
• Strong communication and relationship management skills with providers, executives, and cross-functional teams.

Physical Requirements

• Must be able to sit in a chair for extended periods of time
• Must be able to speak so that you are able to accurately express ideas by means of the spoken word
• Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices
• Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse
• Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types
• Must be able to fluently communicate both verbally and in writing using the English language
• Must be able to engage in continuous social interaction, successfully manage stressful high conflict situations, and balance multiple duties, expectations and responsibilities simultaneously

Time Zone: Eastern or Central

Other Information

• Expected Hours of Work: Monday - Friday 8am – 5 pm; with ability to adjust to Client schedules as needed
• Travel: May be required, as needed by Client
• Direct Reports: None
• Salary Range: $100.00 - $150.00/ hr

EEO Statement

It is Clearlink Partners’ policy to provide equal employment opportunity to all employees and applicants without regard to race, sex, sexual orientation, color, creed, religion, national origin, age, disability, marital status, parental status, family medical history or genetic information, political affiliation, military service or any other non-merit-based factor in accordance with all applicable laws, directives and regulations of Federal, state and city entities. This salary range reflects the minimum and maximum target wage for new hires of this position across all US locations. Individual pay will be influenced by Experience, Education, Specialized Soft Skills, and/or Geographic location.